Mediastinal pancreatic pseudocyst following traumatic rupture of diaphragm

Abstract

Pancreatic pseudocysts are uncommon in children and their extension into the mediastinum is rare. Of the 35 reported mediastinal pseudocysts, only three were seen in children [1][2][3]. These pseudocysts gain access to the mediastinum commonly through the oesophageal or aortic hiatus and rarely through diaphragmatic erosion or foramen of Morgagni [4]. We report an additional pathway through a traumatic defect in diaphragm. Case reportRK, 8 years, male, was admitted with complaints of left chest pain, dyspnoea on exertion, and dry cough following blunt injury of abdomen six months ago. Chest examination re~/ealed diminished air entry and coarse crepitations on left side. Chest x-ray showed left pleurat effusion and diaphragmatic hernia, confirmed subsequently by barium meal (Fig. 1 a, b). An extrinsic impression seen on the lesser curvature of stomach was interpreted as herniated liver and the patient underwent surgery with a preoperative diagnosis of traumatic diaphragmatic hernia.At surger); there was a posteriorly placed tear in the left dome of diaphragm. Stomach, proximal small bowel, left lobe of liver and transverse colon were lying in the left chest cavity. There was a mediastinal pancreatic pseudocyst, 10 × 10 cms in size, and adherent to left lobe of liver, pericardium and lesser curvature of stomach. After mobilization, the pseudocyst and bowel contents were brought into the abdominal cavity. The diaphragmatic defect was repaired and a cysto-gastrostomy done. The child had an uneventful recovery but was re-admitted two weeks after discharge with complaint of vomiting and mass in left hypochondrium. A diagnosis of recurrent pancreatic pseudocyst was made, confirmed by barium meal and ultrasound and another cysto-gastrostomy was done. He has since remained asymptomatic. DiscussionBoth diaphragmatic hernia and pancreatic pseudocyst frequently have a traumatic aetiology. Extension of pancreatic pseudocysts into mediastinum, though uncommon, is also known. But, the association of traumatic diaphragmatic hernia and mediastinal pancreatic pseudocyst has previously not been reported. We did not suspect mediastinal pseudocyst in the pre-operative period due to lack of awareness and absence of any specific localizing clinical features. As a result, no investigation to localize the pseudocyst was attempted. In retrospect, in the presence of blunt abdominal trauma, a persistent left pleural effusion and an extrinsic mass impression on the lesser curvature of the herniated stomach should have made us suspect an underlying pancreatic pathology.Clinical and radiological features of mediastinal pancreatic pseudocysts are well documented [4,5]. Manage-* Formerly pool officer in Radiology, Safdarjang Hospital, present address-lecturer, Department of Radio-Diagnosis, All India Institute of Medical Sciences, New Delhi a n d V. N a t h BaijaP Hospital, New Delhi, India ment is, however, still controversial. Spontaneous resolution of mediastinal pseudocyst has been reported in one patient [6]. External o r internal decompres...

Percutaneous retropleural drainage of a posttraumatic pancreatic mediastinal pseudocyst in a child

“…However, respiratory distress and dyspnea have also been reported [2,7]. The 9 children previously reported in the literature ranged in age from 7 months to 15 years.…”

“…These pancreatic pseudocysts are usually located in the retroperitoneum adjacent to the pancreas. Although extension into the mediastinum is well described in adults [1], only 9 cases of pancreatic mediastinal pseudocysts have been reported in children [2][3][4][5][6]. We report the case of a child with mediastinal pseudocyst secondary to pancreatic trauma, which was successfully treated with computed tomography (CT)-guided percutaneous drainage via a posterior, extrapleural approach.…”